Schemes or plans that examine and seek to achieve enhancement in major areas of clinical and nonclinical services. These plans are usually based on utilization, diagnosis, and outcome information; data from surveys; and grievance and appeals processes. They measure performance at two periods of time to find out if improvement has occurred. These projects are required by the state and can be of the managed care organizations’/prepaid health plans’ (MCOs’/PHPs’) choosing or prescribed by the state.

1. Gauge used to assess the carrying out or execution of a process or function of any organization. 2. Quantitative or qualitative measure of the care and services delivered to enrollees (process) or the end result of that care and services (outcomes). Performance measures can be used to assess other aspects of an individual’s or organization’s performance such as access and availability of care, utilization of care, health plan stability, beneficiary characteristics, and other structural and operational aspects of health care services. Performance measures may include measures calculated by the state from encounter data or another data source, or measures submitted by the managed care organization or prepaid health plan. 3. Information that reveals how well a health plan provides a certain treatment, test, or other health care service to its members. For example, Medicare uses performance measures from National Committee for Quality Assurance’s (NCQA’s) Health Employer Data and Information Set (HEDIS) to get information on how well health plans perform in quality, how easy it is to get care, and members’ satisfaction with the health plan and its doctors.

Quality of care goals that a medical provider is expected to meet such as office hours per week, office visits per month, on-call days, percentage of accounts receivable collected, and surgeries performed per year. Also called performance goals.

Provider who renders a service to a patient; also known as treating physician.

Wide-ranging phrase that means both stillborn infants and neonatal deaths.

Interval from the 28th week of gestation to the 28th day after birth.

1. In an annuity, specific time during which the insurance company unconditionally guarantees benefit payments to continue. 2. In an insurance settlement, time period that the insurer assures payments of benefits.

Beginning and ending time when an insured is not able to perform regular job duties or cannot perform normal activities of a healthy individual of the same age or sex.

1. Phrase used in managed care plan contracts that refers to a reimbursement method that prepays providers for services based on their history of utilization by members. It is a much faster form of reimbursement than other arrangements. 2. Under the Medicare program, cost-based reimbursement method for hospitals before 1983 and the introduction of the prospective payment system (PPS).

Recalibration of Medicare’s relative value scale for financial updating purposes. The Centers for Medicare and Medicaid Services (CMS) must conduct a periodic review every 5 years.